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Loss of Midline Function in Brachial Plexus Birth Palsy Patients
Joshua M. Abzug, MD1; Teresa Wyrick, MD2; Scott Kozin, MD3
1Department of Orthopaedic Surgery, University of Maryland, Baltimore, MD; 2University of Arkansas, Little Rock, AR; 3Shriners Hospital for Children Philadelphia, Philadelphia, PA

Introduction: Brachial plexus birth palsy is a substantial injury to an infant.  While the majority of patients spontaneously recover those who do not have limited motion about the shoulder.  External rotation is most commonly limited, however patients can have loss of internal rotation, either due to the initial injury or secondary to surgical intervention.  Loss of midline function greatly impairs the child’s ability to perform certain activities of daily living such as getting dressed and perineal care.  The purpose of this study was to assess BPBP patients with loss of midline function.

Methods: A retrospective review of all BPBP patients with loss of midline function was performed.  Charts were reviewed for demographic information, extent of BPBP, prior surgical intervention, procedure(s) performed to correct the loss of midline function, complications and outcomes. 

Results: Twenty BPBP patients were identified that had loss of midline function. Nineteen patients underwent tendon transfers about the shoulder with or without arthroscopic capsular release to improve external rotation.  Thirteen of these procedures were isolated latissimus and teres major transfers to the posterior rotator cuff.  Modified mallet scores improved one grade for the categories of abduction, hand to mouth, hand to neck and external rotation without altering the hand to spine category.  However, the internal rotation category decreased from an average of 2.71 pre-operatively to 2.15 post-operatively. Subsequently, nine patients underwent derotational humeral osteotomies to improve midline function.  The average correction of internal rotation during the osteotomy was 47.8 degrees (range; 20-85 degrees).  Modified mallet scores remained unchanged for hand to spine, however, the scores improved back to 2.7 for the internal rotation category.  Global abduction stayed constant at 3.4, external rotation slightly decreased from 4 to 3.75, hand to mouth slightly increased from 3 to 3.25, and hand to neck decreased from 3.75 to 2.38.  Two complications were noted including one plate fracture and one fracture through a screw hole. 

Conclusion:  BPBP patients that undergo surgical procedures to improve shoulder external rotation and/or obtain joint reduction may inadvertently lose midline function.  Derotational humeral osteotomy can effectively restore midline function.  Midline function is needed for BPBP patients to perform activities of daily living.  Surgical procedures to improve external rotation must be performed in a manner that does not cause limitation of midline function.   


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